Tracheotomy is one of the most common life saving operations that is done within medical care. A tracheotomy involves opening a hole in the neck part of the trachea. The term tracheostomy is sometimes used interchangeably with tracheotomy. Strictly speaking, however, tracheostomy usually refers to the opening itself while a tracheotomy is the actual operation.
Some common indications for a tracheotomy are:                Respiratory obstruction—an obstruction of the upper respiratory passages;        Respiratory failure/respiratory insufficiency;        Respiratory paralysis;        Removal of retained secretion;        Reduction of dead space.        
About 15% of all patients treated in intensive care units need a tracheotomy.
Tracheotomy was already performed in ancient times. Of course, the procedure was at that time associated with high risk and was consequently rarely performed up to the beginning of the twentieth century. At that time Chevalier Jackson described routines for performing the procedure, which lead to making the procedure safer and even more common. He described what is called open tracheotomy.
Open tracheotomy is a surgical operation that is performed in an operating theatre by a surgical team that consists of an ear, nose and throat surgeon, and preferably an assisting surgeon, as well as a theatre nurse, an anesthesiologist, and an anesthesia nurse and also a nurse's assistant. A sterile sheet environment is necessary. It is preferred to perform the operation on an intubated patient in anesthesia together with supplementary local anesthesia in the surgical area. During acute situations, when intubation is difficult or impossible to be done, the surgical operation is performed with the patient awake, in local anesthesia. A horizontal incision is made in the skin above the breastbone (above the suprastenal notch). Then, a cut is performed sharply through the platysma. The straight neck muscles are pulled aside. However, the thyroid gland isthmus should preferably be avoided, but if it is in the way, it is split and bound up. The trachea is then opened with a horizontal incision for adults and with a vertical incision for children. A tracheal tube is inserted and connected to a respirator. Then the wound is closed with sparse sutures and finally the tube is fixed with sutures and tracheal bands.
During the last thirty years even so called percutaneous tracheotomy has been established. This technique became widely spread despite highly frequent complications. The frequency of complications could be reduced considerably by introducing an endoscopical guidance. The result of this development was that the indications for a tracheotomy changed and specialists who perform a tracheotomy, who earlier exclusively were ear, nose and throat specialist, include now even intensive care physicians.
Furthermore, percutaneous tracheotomy was already described during the sixties, but was not accepted as a secure surgical operation before the eighties when the group of Ciaglia introduced dilatators. The surgical operation may be performed bedside on an intensive care unit in anesthesia by two trained physicians, whereof one carries out the surgical operation and the other inspects the trachea from the inside by means of a bronchoscope. Moreover, an anesthesia nurse is necessary.
The surgical area is locally anesthetized and a horizontal incision is made in the skin. A cuffed endotracheal tube is pulled up against the vocal cords. The tracheal wall is, under inspection via a bronchoscope, punctured with a needle through the endotracheal tube. Subsequently a guidewire is introduced. On the latter a dilatator having increasing gauge is then introduced. Finally, a tracheal tube, which is slipped on a dilatator, is introduced into the tracheostoma that is produced. The dilatator is withdrawn and the tracheal tube is positioned. The method does not leave any wounds that have to be sutured, and the tracheal tube is fixed in the same manner as with open technique. The patient's head must be kept centered, such that the puncture does not end up aside of the trachea. The position of the percutaneous tracheotomy is also located 2 cm above the breastbone.
The surgical operation necessitates staff that is acquainted with this technique. A number of surgical operations under experienced supervision are necessary before it can be performed independently. The frequency of complications is rather high and comprises amongst others pneumothorax, perforation of the rear tracheal wall and oesophagus, as well as bleedings. The procedure is complicated with patients who have a short and thick neck, and patients having enlarged thyroid gland. It is not recommended for children.
The percutaneous technique has eliminated drawbacks that an open tracheotomy involves, including the need of an operation theatre and staff intensive effort, and that it leaves an open wound that can become an infection site. Furthermore, it also puts heavy demands on surgical skill training. Moreover, the open technique is burdened with the risk of surgical complications.
Hence, there is a need for an improved tracheotomy technique. In particular a device and method allowing for increased flexibility, cost-effectiveness, as well as patient safety and comfort would be advantageous.